Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Getting to Zero:
Diverse Methods for Male Involvement
in HIV Care and Treatment
Since 1943, Catholic Relief Services has been privileged to serve the poor and
disadvantaged overseas. Without regard to race, creed, or nationality, CRS
provides emergency relief in the wake of natural and manmade disasters. Through
development projects in fields such as education, peace and justice, agriculture,
microfinance, health, and HIV and AIDS, CRS works to uphold human dignity and
promote better standards of living. CRS also works throughout the United States
to expand the knowledge and action of Catholics and others interested in issues of
international peace and justice. Our programs and resources respond to the U.S.
bishops’ call to live in solidarity—as one human family—across borders, over oceans,
and through differences in language, culture and economic condition.
Catholic Relief Services
228 W. Lexington Street
Baltimore, MD 21201-3413 USA
©2012 Catholic Relief Services—United States Conference of Catholic Bishops. Published 2012.
Author: Adele Clark
Reviewers: Trish Ahern, Dorothy Brewster-Lee, Kate Greenaway, Brenda Hegarty,
Carrie Miller, Karen Moul, Shannon Senefeld
The following people contributed information to this paper:
AIDSRelief Zambia: Dr. Sylvester Chilaika, Dr. Mope Shimabale, Dr. Annie Mwila, Ms.
Linah Mwango, Ms. Bridget Chisenga, Ms. Grace Mshanga, Ms. Dorcas Phiri, and
Marcqueline Zulu
AIDSRelief Kenya: Dr. Subiri Obwogo
Holy Family: Colleta Wafula and Ezekiel Israel Were
Maua Methodist Hospital: Stephen Gitonga
AIDSRelief Uganda: Molly Tumusiime and Sheila Nyakwezi; the Futures Group team
in Uganda provided data analysis
AIDSRelief Nigeria: Lauren Pelascini, Julie Ideh, and Adedotun Omitayo
Cover photo: Karen Kasmauski for CRS
This publication was funded by Catholic Relief Services and the views described herein are
those of the authors. The contents are solely the responsibility of CRS and do not necessarily
represent the official views of HRSA, CDC or the United States government.
Important note: the photographs are used for illustrative purposes only; they do not imply
any particular health status on the part of any person who appears in the photographs.
Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Background
Women and girls continue to be disproportionately affected by
HIV, representing approximately 60 percent of those living with
HIV in sub-Saharan Africa.i Women and girls are also more likely
to be isolated within the domain of the home and to lack decisionmaking power over their time, finances and movements. As such,
healthcare providers must make a special effort to reach them.
While bringing HIV services to women and girls is critical,
research shows that interventions are often more meaningful and
lasting with the active participation of men and boys.ii Particularly
in the context of heterosexual transmission of HIV, failing to
get men in for prevention, testing and treatment services hurts
women and families and thwarts efforts to contain HIV.
Men may fail to access HIV prevention and treatment services for
reasons that include occupation, residence, employment-related
migration, social norms and cultural beliefs.iii They often wait
longer than women to access treatment and are more likely to
be lost to follow-up.iv Outreach to women for care and treatment
services has been comparatively more successful. Together,
these reasons lead to late HIV diagnosis (including lower CD4
baseline values), the emergence of HIV sequelae and higher crude
mortality rates among men.v
The ambitious UNAIDS goal of “Getting to Zero”vi cannot be
achieved by reaching only half of the population; prevention
and treatment must reach both sides of the equation – men and
women – to get to zero. Increasing men’s involvement in caring
for their own health and that of their families requires creative
solutions. Catholic Relief Services, through AIDSRelief, has been
increasing awareness about the need for men’s involvement and
deliberate in its efforts to attract and retain men in its programs.
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Emmanuel first brought his wife of 35 years, Angelna, for treatment when she was very sick.
Both are receiving treatment and now, he says, “she is so strong, she can push down a tree.”
Karen Kasmauski for CRS.
Catholic Relief Services (CRS) seeks to address the unique roles,
relationships, responsibilities and opportunities of men, women,
boys and girls to meet their own needs and achieve their full
rights, responsibilities and opportunities. Gender considerations
are essential to developing strategies and programs for individuals
and communities.vii CRS programming is sensitive to the varied
roles and responsibilities of men, women, boys and girls in the
household and in society, and across many contexts and cultures.
Applying a gender lens does not divert from the mission of
stopping the impact and spread of HIV, rather it helps to fulfill it.
For more than two decades, CRS has been providing care and
support for people affected by HIV. Since 2004, AIDSRelief, a
five-member consortium, has provided HIV care and treatment
for nearly 700,000 people in poor and underserved communities
in ten countries, including more than 220,000 who were on
antiretroviral therapy (ART) as of December 2011. AIDSRelief
is funded through the U.S. President’s Emergency Plan for AIDS
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Relief (PEPFAR) and brings together international expertise in
HIV care and treatment: CRS as prime grantee; the University
of Maryland School of Medicine Institute of Human Virology
as technical lead for clinical care and treatment; Futures Group
as lead agency for strategic information; IMA World Health and
Catholic Medical Mission Board as implementing partners; and
Children’s AIDS Fund as a key sub-grantee operating sites in
Uganda and Zambia.
AIDSRelief has provided a flexible environment for testing clinicand community-based strategies that foster men’s involvement in
HIV prevention, care, treatment and support. In seven years of
operation, AIDSRelief has greatly expanded gender responsiveness
in its programming. This paper shares the strategies used by four
AIDSRelief country programs for increasing men’s involvement in
HIV treatment and adherence to antiretroviral therapy (ART).
AIDSRelief Strategies for Increasing
Male Involvement
Using a gender analysis process to stimulate
gender-responsive thinking
AIDSRelief Nigeria took the important, but often neglected, step of
conducting a gender analysis of its program. While not exhaustive,
the analysis stimulated gender-responsive thinking among staff
and created a springboard for future action. Gender analysis can be
mistakenly used to identify only missed opportunities for women
and girls, but AIDSRelief Nigeria considered the full dimensions of
gender—both male and female norms, roles and expectations—and
responded to this in their programming.
Findings from the gender analysis included:
• The AIDSRelief Nigeria program responded to the
epidemic’s disproportionate effect on women and girls by
specifically targeting them with HIV services. Reflecting
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
the success of an extensive prevention of mother-to-child
transmission (PMTCT) program, the number of female
clients enrolled in AIDSRelief Nigeria was nearly double the
number of males. In AIDSRelief Nigeria’s support groups,
nearly 80 percent of participants were women.
• Men and boys were under-represented in several care and
treatment interventions, pointing to a need for more effective
outreach and a focus on improving uptake.
• While the robust monitoring system captured sex- and agedisaggregated data, reports were underutilized as a basis for
analyzing the gender implications of the program’s structure.
The addition of more finely-tuned indicators and/or the use of
reflective questions during data analysis were recommended.
• The gender ratios of the AIDSRelief Nigeria and CRS senior
staff, with women and men equally represented, were found
to be a strength of the program. However, the gender analysis
process pushed them further, leading to a gender training that
addressed the norms and expectations of both women and men
on the staff. AIDSRelief Nigeria plans to extend gender analysis
opportunities to partners with the aim of addressing the sex-ratio
and gender sensitivity of partner staff and volunteers.
Summary of AIDSRelief Nigeria’s strengths and
recommendations for improvement
Strengths
4
Recommendations
Services to women and girls
(aged 15+ years)
Increase partners’ counseling
Increase couples’ testing
Increase involvement of men and
boys in support groups
Sex and age
disaggregated data
Include checklist of questions to
improve gender analysis of monthly
service data
CRS staff and AIDSRelief Nigeria
staff include appropriate male/
female ratios*
Conduct gender analysis of partner
staff and volunteers
* As self-defined by CRS Nigeria staff via group discussion and consensus building.
Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
As an outcome of the gender analysis process, CRS Nigeria
conducted a gender awareness workshop for all staff. In the
workshop, staff engaged in participatory exercises that explored
the basic concepts of gender and fostered increased gender
awareness within programming, the workplace and home. The
workshop culminated in the development of an action plan
which included the formation of a Gender Committee to followup on the next steps generated in the workshop.
Both the gender analysis process and the awareness-raising
workshop provided a context for re-thinking gender norms
and spurring staff creativity and motivation to improve gender
responsiveness in AIDSRelief programming.
The successful promotion of voluntary medical
male circumcision
AIDSRelief was involved in promoting voluntary medical male
circumcision (VMMC) by making it available at the clinics and
by promoting it within communities. At the time of writing,
two AIDSRelief country programs, Kenya and Zambia, had
introduced VMMC in several sites. In Zambia, 11 of 19 local
partner treatment facilities provided VMMC through partners
like Jhpiego and FHI 360. In Kenya, eight of 29 local partner
treatment sites offered VMMC in Nyanza province, where HIV
prevalence is the highest in the country (13.9 percent versus the
national average of 6.3 percent)viii.
Where VMMC is available, AIDSRelief played a role in
promoting uptake of services through multiple providerinitiated clinic-based entry points and via church channels,
community health volunteers and health care worker outreach
visits. Once they come to the clinic for VMMC, they are
introduced to the full range of HIV-related services offered at the
clinic including counseling and testing, PMTCT, support groups,
etc., that can help to protect them and their partners.
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Recognizing the importance of support groups
for men
Studies from diverse cultures consistently show that often men
do not seek health services until it becomes absolutely necessary
to do so. Many studies have confirmed that social constructs
of masculinity act as a barrier to accessing HIV services for
men.ix In some places, men do not seek services because clinics
are considered “women’s spaces”x and they are placed in the
subordinate position of learning from a female health worker
which challenges their views of masculinity.xi HIV, in particular,
is considered a threat to manhoodxii and a sign of a man being
unable to control his sexuality or to protect himself.
The formation of support groups specifically for men provides
men with dedicated social space to negotiate, question, and
re-form their concepts of masculinity. Through these groups,
men often maintain their masculine identity as the provider and
protector, but they re-define the behaviors necessary to fulfill
their role.xiii Support groups also perform a very important
role as a safe space in which men can be vulnerable, access
peer support and counseling for grief and anger, work through
the emotions that come with an HIV diagnosis and share
experiences with those in a similar situation.
Within AIDSRelief, men’s support clubs organically developed
in five local partner treatment facilities (LPTFs) in Zambia and
Kenya. In Zambia, “Men Take Action” groups, made up of both
those affected by and those living with HIV, were hosted at LPTFs
in Mtendere, Siavonga and Mwandi. In Kenya, a men’s support
club started at the Nangina Holy Family treatment facility grew to
24 members. At another Kenyan site, three district support groups,
comprised of 70 members and locally registered, formed at the Maua
Methodist Hospital. Group members benefit from psychosocial
support and access to income generating activities; their families
benefit through the participant’s adherence to ART and through
being encouraged to participate in counseling and testing and
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
PMTCT services. The community benefits from these men doing
outreach and advocacy; they are invaluable as champions or role
models of a redefined masculinity—one which seeks services and
takes responsibility for protecting the health of his family.
At Maua Methodist Hospital in Kenya, the founder of the Maua
male support group was a member of the local community’s Meru
council of elders called Njuri Ncheke, the highest decision-making
body in the community. The Maua men’s support group wanted to
share their “secret” of “bouncing from the jaws of death and back”
with other men who were “hiding and dying needlessly from AIDS
as a result of stigma and discrimination.” The men felt that they had
been rescued from fear and sickness and wanted to rescue others.
-Report from Dr. Subiri Obwogo, Deputy Chief of Party for AIDSRelief Kenya
While Zambia’s and Kenya’s men’s support clubs formed
organically, the formation of men’s support groups in Uganda
was facility-driven and for a specific purpose. In Uganda, staff
noted many struggles in getting men to support their partners
in PMTCT services—including the abandonment of mothers
who were found to be living with HIV. The treatment facility
in Kasanga started an active PMTCT support club that wanted
to increase men’s participation. While initiated at the clinic,
the PMTCT support clubs moved into the community, holding
meetings on weekends and for shorter periods of time, to attract
male members. Male community leaders led the support groups
and members shared their experiences. Efforts to make the
PMTCT clubs friendly for men resulted in increased support of
their female partners in PMTCT services.
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Strengthening couples’ relationships and
encouraging couples’ testing
AIDSRelief Uganda established a
THE FAITHFUL HOUSE
linkage between antenatal care services
A Couple’s Guide to PMTCT
and The Faithful House (TFH) program.
TFH is a faith-based, skills-building
curriculum created collaboratively by
CRS and Maternal Life International/
Uganda. The goal of the program is
to reduce the vulnerability of families
to HIV transmission through family
strengthening. TFH core curriculum was
adapted to address key implementation challenges identified in
the PMTCT project, such as HIV couples’ testing and counseling,
disclosure of HIV status between couples, ART adherence
(mother and baby), support for mothers to attend antenatal care
and deliver babies at health facilities, and support for feeding
options for babies born to mothers living with HIV.
Catholic Relief Services
in collaboration with
MATERNAL LIFE INTERNATIONAL
MATERNAL LIFE UGANDA
CRS UGANDA
Couples-focused voluntary counseling and testing is effective
because the full package of care can be made available to the
entire family from the point of diagnosis. Through linkages
with TFH, AIDSRelief Uganda established this continuum of
care. Women who came to local partner treatment facilities
for antenatal care were referred, with their partners, to TFH;
through the program, communication and equity in the
relationship was improved. An operations research study
completed in March 2011 found that half of the couples in
Uganda who participated in TFH went on to be tested for HIV,
where 6.2 percent of participants learned of their HIV-positive
status and were successfully referred into the AIDSRelief
program for care, treatment and PMTCT services. The linkage
between AIDSRelief Uganda and TFH program ensured a
continuum of care by encouraging testing of entire families and
enrolling families together in treatment and PMTCT services.
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Waswa and Agnes Vincent in Uganda participated in The Faithful House and now have a
stronger marriage and a healthy baby girl. Photo by CRS Staff.
Involving men in antenatal care and PMTCT services
HIV-positive women whose partners attend PMTCT services are
more likely to adhere to treatment and appropriate infant feeding
methods.xiv AIDSRelief programs in Zambia and Uganda actively
reached out to partners of women receiving antenatal care or
PMTCT services.
AIDSRelief Zambia, through its partners, offered clinic-based
incentives and community advocacy to encourage men’s greater
participation in antenatal care. Women who came for care
without their partners were still treated, but were counseled on
the importance of bringing their partners for testing. Women
who came with their partners were attended to first and
offered snacks. Provider-initiated testing and counseling was
the standard policy for all Zambia sites, so that each partner
accompanying for antenatal care services was also tested and the
couple received counseling.
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
The Siavonga District Hospital in Zambia, where 85 percent
of pregnant women are accompanied by their partners for
antenatal care visits, is a success story of advocacy and community
mobilization. First, AIDSRelief staff conducted community
awareness activities in the churches and staff training with the
nurses to sensitize them to the importance of men’s involvement
in women’s antenatal care visits. Next, the Maternal Child Health
team at the hospital presented the need for men’s involvement
to the hospital management. The government structures were
engaged when hospital management discussed the problem with
the District Commissioner. An enabling environment was created
when the District Commissioner took the problem to the heads of
departments to engage them in appealing to supervisors for men to
accompany their wives for care. As a result, 85 percent of pregnant
women presenting for care come with their partners, who are then
tested for HIV and included in couples’ counseling.
In addition to the linkages with The Faithful House, AIDSRelief
Uganda has also put in place other activities to encourage men’s
involvement in antenatal care. The local partner treatment
facilities trained on couples’ counseling. In addition, the
space used for antenatal care services provided a venue for
couples’ meetings. AIDSRelief Uganda also found success
in issuing “love letters” to men inviting their participation in
accompanying their partners to antenatal and PMTCT services.
Written invitations increased men’s participation in antenatal
care and increased uptake of voluntary counseling and testing.xv
AIDSRelief Uganda sends out “love letters” from women attending
antenatal care and PMTCT and services to invite male partners to
follow-up visits. Women and their midwives draft letters using the
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
words that the women feel will draw her partner to the clinic.
Several form letters have been created, so that women can now
choose from an existing letter and personalize it with names and
dates. The letters include information about upcoming meetings in
the community or at the clinic on the topic of healthy pregnancy.
The clinician signs and stamps the letters to make them official and
the women deliver them to their partners. The greater number of
men attending information meetings and being referred for testing
is a direct reflection on the success of this activity.
Lessons Learned
While AIDSRelief’s mandate for rapid-scale up in poor and
remote areas required intense and focused energy, the program
also provided a platform for flexible, adaptive, genderresponsive programming. AIDSRelief strategies for improving
men’s involvement called for a better evaluation of interventions
and their outcomes and provided some creative methods for
men’s involvement.
• Gender analysis of programs and policies and gender
training for staff can begin a series of small changes which
ripple throughout the program. AIDSRelief Nigeria
experienced how even a brief look at gender-responsiveness
within their program could lead to a demand for more
training, which led to a committee charged with following
up on action plans. As AIDSRelief transitions to local
partners, partner staff should build on the progress of
AIDSRelief Nigeria by engaging in their own gender
analysis and gender-responsive policies and programs.
• Futures Group developed strong monitoring and evaluation
systems within AIDSRelief. These systems monitored
and responded to client adherence and loss to follow-up
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
through the collection and strategic use of high quality
data (disaggregated by sex and age). The gender analysis
conducted by AIDSRelief Nigeria revealed the need to
take this a step further. As a result, future monitoring may
include indicators such as “percentage of female clients
accessing antenatal care services with their male partner”;
and “number of men and boys participating in healthcare
facility outreach.” Staff could develop guiding questions for
gender analysis that draw out the implications of the data
collected. The gender-responsiveness of ART programs
would be strengthened by the inclusion of gender indicators
for treatment programs.
• Targeting men with multiple, appropriate services
encourages uptake and maximizes the effect of every visit
that men make to a clinic. Provider-initiated counseling
and testing in AIDSRelief Zambia and Kenya was one
standard operating procedure which ensured that all men
who crossed the clinic threshold were entered into services.
Men who accompany partners for antenatal or PMTCT
services should not play a passive role in the waiting room;
they should be engaged in counseling and referred for
appropriate services. Likewise, men entering the clinic for
VMMC, such as those in Kenya or Zambia, are targeted for a
range of preventative services.
• For the most effective care, the clinic’s efforts should be
complemented by community outreach and wrap-around
services. A definite strength of AIDSRelief was its ability
to work at both the clinic and community levels with the
referral network between AIDSRelief Uganda and The
Faithful House program as an outstanding example of this
complementarity.
• Men’s involvement in HIV prevention and treatment
requires male champions to promote behavior change.
Treatment facilities can create an enabling environment
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
for fostering leadership by encouraging men’s support groups.
Whether men’s support groups develop organically as they
did in AIDSRelief Zambia and Kenya, or whether the clinic
deliberately establishes men’s groups for a specific purpose, they
form a space for men to renegotiate their masculine identity and
to support one another in creating a new social norm.
• AIDSRelief sites in Uganda and Zambia exhibited their
willingness to be innovative and to take risks. The love
letters method is a clinic-initiated method of establishing
communication between spouses and engaging partners in
antenatal and PMTCT care. AIDSRelief Zambia took risks in
incentivizing partner participation in care through clinicbased prioritization of couples and through community
advocacy with local government and labor leaders.
Incentivizing methods need to be carefully monitored for
exclusionary results, but may be a positive way to reach the
whole family.
Conclusion
Throughout implementation, AIDSRelief took small, gradual
steps to increase men’s involvement in the HIV response; it
is hoped that sharing these experiences will encourage the
transition and expansion of these efforts to local partners.
The UNAIDS goal of “getting to zero” requires thoughtful
and creative approaches for reaching each member of the
population. AIDSRelief has demonstrated flexible programming
and innovative approaches which reach out to men and which
ultimately improve health outcomes for everyone.
i
ii
UNAIDS, 2011 World AIDS Day Report. (Geneva: UNAIDS, 2011).
Emily Esplan, Engaging Men in Gender Equality: Positive Strategies and Approaches
(United Kingdom: Institute of Development Studies, 2006).
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
Edward J. Mills, et al., “Male gender predicts mortality in a large cohort of patients
iii
receiving ART in Uganda,” Journal of the International AIDS Society 14 (2011):52.
Vincent Ochieng-Ooko, et al., “Influence of gender on loss to follow-up in a
iv
large HIV treatment programme in western Kenya,” Bulletin of the World Health
Organization 88 (2010): 681–688.
Edward J. Mills, et al., “Male gender predicts mortality in a large cohort of patients
v
receiving ART in Uganda,” Journal of the International AIDS Society 14 (2011):52.
UNAIDS, UNAIDS 2011-2015: Getting to Zero (Geneva: UNAIDS, 2011).
vi
Catholic Relief Services, Gender: Promoting Right Relationships to Strengthen
vii
Families and Communities (Baltimore: CRS, 2011).
Kenya National Bureau of Statistics (KNBS) and ICF Macro, Kenya Demographic
viii
and Health Survey 2008-09. Calverton, Maryland: KNBS and ICF Macro, 2010.
Morten Skovdal, et al., “Masculinity as a barrier to men’s use of HIV services in
ix
Zimbabwe,” Globalization and Health 7 (2011): 13.
x
Gary Barker and Christine Ricardo, Young Men and the Construction of Masculinity
in Sub-Saharan Africa: Implications for HIV/AIDS, Conflict and Violence, Social
Development Department Working Paper Series No. 26 (Washington, D.C.: The
World Bank, 2005).
Morten Skovdal, et al., “Masculinity as a barrier to men’s use of HIV services in
xi
Zimbabwe.” Globalization and Health 7 (2011): 13.
xii
Morten Skovdal, et al., “When masculinity interferes with women’s treatment
of HIV infection: a qualitative study about adherence to antiretroviral treatment
in Zimbabwe,” Journal of the International AIDS Society 14 (2011):29.
xiii
Christopher J. Colvin and Steven Robins, “Positive Men in Hard, Neoliberal
Times: Engendering Health Citizenship in South Africa,” in Gender and HIV/
AIDS: Critical perspectives from the developing world, ed. Jelke Boesten and Nana
Poku. (Farnham, UK: Ashgate Publishing Limited, 2009), 177-190.
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Getting to Zero: Diverse Methods for Male Involvement in HIV Care and Treatment
xiv
SE Msuya, et al., “Low male partner participation in antenatal HIV counseling
and testing in northern Tanzania: implications for prevention programs,” AIDS
Care 20 (2008): 700-709.
xv
BK Mohlala, et al., “The forgotten half of the equation: randomized controlled
trial of a male invitation to attend couple VCT in Khayelitsha, South Africa,”
AIDS 25 (2011): 1535-1541.
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to Zero:
Diverse
Methods
for Male Involvement in HIV Care and Treatment
THEGetting
AIDS RELIEF
SOUTH
AFRICA
PARTNERSHIP
Catholic Relief Services
228 West Lexington Street
Baltimore, MD
21201-3413 USA
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